Bad Bugs, No Drugs…. :Bad Bugs, No Drugs….


Preantibiotic Age :Preantibiotic Age Tuberculosis and pneumonia responsible for 25% of deaths in US (1900). More people died in wars due to infection than to actual traumatic injury. Syphilis treatment pre 20th Century !..


Discovery of penicillin 1928 :Discovery of penicillin 1928 Alexander Fleming Nobel Prize, 1945


The Golden Ages! :The Golden Ages! 1969, Surgeon General of United States: “It is time to close the book on infectious diseases”. 1977- Smallpox - global eradication. 1990- TB and pneumonia caused less than 4% of deaths. 1995- Measles - record low level.


Warnings of resistance! :Warnings of resistance! Alexander Fleming (discoverer of penicillin) recognized the potential danger of antibiotic resistance. In 1945, he warned that misuse of penicillin could lead to the selection and propagation of mutant forms of bacteria resistant to the drug.


Resistance Arrives: 1951 :Resistance Arrives: 1951 The first penicillin-resistant bacteria appeared in 1951. Their mutant gene encoded for a penicillin-destroying enzyme, penicillinase.


Today drug resistance threatens to reverse medical progress... :Today drug resistance threatens to reverse medical progress... Curable diseases – from sore throats and ear infections to TB and malaria -- are in danger of becoming incurable. Reports warn that increasing drug resistance could rob the world of its opportunity to cure illnesses and stop epidemics.


Neisseria gonorrhoeae. :Neisseria gonorrhoeae. More than 50% are resistant to penicillin or tetracycline or both. SE Asia, ~98% are penicillin resistant. Resistance to ciprofloxin increasing. Gonorrhoea increases shedding of HIV, may also increase susceptibility.


Mycobacterium tuberculosis :Mycobacterium tuberculosis 1/7 new TB cases is resistant to first line TB drugs (5% die). Cost of treating one person with multidrug-resistant TB is 100 times greater than the cost of treating non-resistant cases. NYC spent $1 billion to control outbreak of multidrug-resistant TB in early 1990s.


Shigella (dysentery) :Shigella (dysentery) In Japan, in 1953, only 0.2% of Shigella (causes bacillary dysentery) was resistant to antibiotics. By 1965, 58% were resistant to sulfnilamide, streptomycin, chloramphenicol, and tetracycline. Ten years ago, a shigella dysentery epidemic could easily be controlled with drugs cheaply available in generic form. Today, nearly all shigella are unresponsive to these drugs.


Therapy priced out of the reach of the poor.... :Therapy priced out of the reach of the poor.... Thailand has completely lost the use three of the most common anti-malaria drugs because of resistance. A small but growing number of patients are already showing primary resistance to AZT and other new therapies for HIV-infected persons. A decade ago in New Delhi, India, typhoid could be cured by three inexpensive drugs. Now, these drugs are largely ineffective in the battle against this life-threatening disease.


Developing Countries... :Developing Countries... In many parts of the world, incompetent medical prescribing, inadequate patient education & support, counterfeit drugs, poverty, transportation difficulties and unreliable drug supplies all potentiate the emergence of drug resistance.


Developed Countries :Developed Countries In wealthy countries, resistance is emerging for the opposite reason – the overuse of drugs. Unnecessary demands for drugs by patients are often eagerly met by health services and stimulated by pharmaceutical promotion Overuse of antimicrobials in food production is also contributing to increased drug resistance. Currently, 40% of all antibiotic production is used in agriculture. Globalization, increased travel and trade ensure that resistant strains quickly travel elsewhere. So does excessive promotion.


Roadblocks :Roadblocks Only 4 large pharmaceutical companies with antibiotic research programs remained in existence in 2002. Research and development of a new antibacterial can take 10-15 years and cost over €500 million. Unattractive profitability of antibiotics (Pharmaceutical companies want largest usage from products).


Trends in Development of New Antibacterials. :Trends in Development of New Antibacterials.


Roadblocks Continued.... :Roadblocks Continued.... Antibiotics continue to be over prescribed and are still sold illegally over the counter in some EU countries. Farmers resist bans on agricultural use.


..... :..... “Big” Pharma sees better return from the treatment of chronic diseases. In contrast, antibacterial therapies are: Costly to develop. Short course, used for acute illnesses. Not embraced by the marketplace Rarely “blockbusters”.


Agricultural use of antibiotics :Agricultural use of antibiotics >40% of all antibiotics manufactured. Treatment of disease in animals Prevention of disease in animals. Growth promotion and improved feed efficiency. Spraying of fruit trees and vegetables to prevent fire blight.


Consequences of Agricultural Antibiotic Use :Consequences of Agricultural Antibiotic Use Campylobacter fluoroquinolone resistance. MRSA in pork. Gentamycin- and Cipro-resistant E. coli in chickens.


Consequences of Agricultural Antibiotic Use. :Consequences of Agricultural Antibiotic Use. Centre for Disease Control (CDC): “Antibiotic use in food animals is the dominant source of antibiotic resistance among food-borne pathogens.” Three years after a Danish ban on routine use of antibiotics in chicken farming, the prevalence of antibiotic-resistant bacteria in chickens dropped from 82% to 12%.


Agricultural Antibiotics :Agricultural Antibiotics 01/01/06: European Union bans antibiotics as growth promoters in animal feed. 2008: United States Department of Agriculture allows E. coli-tainted meat to be sold as pre-cooked hamburger patties, taco meat, pizza toppings, etc.


Slide 24:To date this year we have spent €11,632 on antibiotics (3.5% pharmacy expenditure). 4 courses of Zyvox- €2,377 (€60 per tablet!).


SARI: A Strategy for the Control of Antibiotic Resistance in Ireland :SARI: A Strategy for the Control of Antibiotic Resistance in Ireland


SARI- :SARI- Antibiotic pharmacists in 3 hospitals. Infection Control Nurse in 4 hospitals. Surveillance scientist 0.5 post. Consultant Microbiologist 0.4 post. Laboratory surveillance scientists in 4 labs.


Patient guidelines :Patient guidelines Don’t insist on antibiotics when your doctor says they are not needed. If you are prescribed drugs, take the full course. Never hang on to unfinished prescriptions with the intention of using them for new ailments. Never share antibiotics with others. Keep a diary of antibiotic use. In Ireland we currently consume twice as many antibiotics as the Netherlands


Physician guidelines :Physician guidelines Reduce inappropriate use of antibiotics (G.P’s). Meticulous infection control, especially in hospitals and long term care facilities. Promote good prescribing practice. Reduce use of broad spectrum antibiotics, use narrow spectrum antibiotics when possible. Urge patient compliance. Increase monitoring, surveillance & audit.


Prescriptions for Antibacterial Drugs :Prescriptions for Antibacterial Drugs Prescription volumes for antibiotics are declining


Postponing the end of the antibiotic era :Postponing the end of the antibiotic era Antibiotic stewardship (prudent use) Contain the spread of resistant micro-organisms and relevant genes (infection control) Develop new antibiotics that have novel modes of action or circumvent bacterial mechanisms of resistance (research)


Thank you :Thank you Infectious diseases remain the second leading cause of death worldwide. Becoming complacent about the need for new antibiotics is a dangerous strategy.